Why cancer care isn’t ‘one-size-fits-all’ from one country to another

Six years ago, when Dr. Fabio Ynoe de Moraes was a resident in radiation oncology in São Paulo, he began to ask questions about cancer patients’ access to radiation in Brazil. How many LINAC systems (linear accelerator radiation machines) were there in the country? Where were they?

His mentor agreed that he could devote time to researching this question. He spent almost a year developing a map of every machine in Brazil, a country of more than 212 million people that’s geographically almost as large as the United States. And then he studied statistics about cancer rates.

“We calculated that only 45 to 47 per cent of those who would need radiation in their lifetime had access, and that 53% of cancer patients die without access to basic treatment.”

When Dr. Ynoe de Moreas published his findings, they caught the attention of the country’s Ministry of Health, and the government fostered the development of a plan to increase capacity and access to radiation treatment. The government is now implementing, over five years, a program to purchase 100 machines so that 95 per cent of cancer patients will have access to radiotherapy. The plan includes training people to use and maintain the machines.

“One of the biggest challenges is we do research but it rarely has an immediate impact on populations,” Dr. Ynoe de Moreas says. “I started to understand more about policy and got really excited. When you do policy and population research, you can improve care for thousands or more people.”

Dr. Ynoe de Moreas, who joined the Department of Oncology at Queen’s last year, now divides his time between clinical work and research/policy work and this year he is defending his PhD on Innovation in Health Care in Brazil. A former tennis pro, he applies the discipline and focus from that experience. Before heading to his clinical work at Queen’s, he spends his early morning hours doing policy work and global oncology research.

A major endeavour has been his international work completing a checklist for National Cancer Control Plans (NCCPs) with colleagues on the Union for International Cancer Control, Australia and World Health Organization. The biggest challenge in developing the list was “the amount of information and finding consensus among peers,” he says.

Dr. Ynoe de Moreas was a co-lead author of a policy review of this research that was published in Lancet Oncology last November.

The checklist, which consists of more than 100 core elements of a plan, builds on previous work by the World Health Organization. Most countries already have a national non-communicable disease plans, and a large proportion of those also have NCCPs. But these plans don’t always have common elements and most have not been implemented or even assessed for its quality.

Dr. Ynoe de Moraes and his colleagues discovered that a large number of previous plans did not specifically acknowledge childhood cancer — a major cause of mortality in lower income countries —nor the need for sustainable plans for machine maintenance. This new developed checklist takes both of those, and other factors, into account.

Similarly, strategies to actively encourage access to care for underserved populations had not been stressed. Dr. Ynoe de Moraes contributed to research that promoted this approach after establishing that a high proportion of men in Nigeria, a country with a high rate of prostate cancer mortality, believe they are immune to cancer. “Some believed breast cancer was the only cancer possible,” he says. “Or that cancer only happens to women.”

The checklist is designed to allow countries to establish a baseline of existing cancer prevention, diagnosis, and treatment resources. They can then implement a plan that is based on the resources that they have, and measure progress towards reducing the burden of cancer and improving the quality of life of patients. Dr. Ynoe de Moraes hopes to see more and more countries taking this kind of action.

With regional leaders at the helm, he believes that we will see real progress towards improving cancer control, and a reduction in the gaps in cancer care – the very gaps that first caught his attention when he was completing his residency in Brazil.